Example of a Completed Allergen Immunotherapy Prescription

Example of a Completed Allergen Immunotherapy Prescription Patient Name: Jerry Cleanex Prescribing Physician: Dr. Ah Choo Patient Number: 23456 Address: 665 Rosebud Lane Birth Date: 05/05/90 Hollywood, Fl. 33424 Telephone: 645-345-0987 Telephone: 645-123-4444 Fax: 645-123-4567

Vaccine Name: C, R, G, T, W Maintenance Concentrate Prescription Form Bottle Name Abbreviations Tree: T Mold: M Prepared by: Mary Lancet Date Prepared: 6/10/08 Grass: G Cat: C Weed: W Dog: D Ragweed: R Cockroach: Cr Mixture: Mx Dust Mite: Dm

* Components of mixes listed on a separate sheet Antigen Extract Name Concentration and Volume of Extract Lot Number Expiration Number Allergen or Diluent Type Manufacturer’s Manufacturer Date (Common name or Manufacturer’s Extract to Add* Genus/species)* Extract (AU, BAU, W/V, PNU)/ (50% G, Aq, Ly, AP) 1 Short ragweed 1:10 w/v G 0.25ml Greer 12345 1/01/10 (350 Amb a1) 2 D. farinae 10,000 AU/ml G 0.5 ml Allermed 5765 2/06/10 3 D. Pteronyssinus 10,000 AU/ml G 0.5ml Antigen labs 4222 3/24/08 4 Cat 10,000 BAU/ml G 2.00ml Hollister–Stier 9898 2/27/10 5 Timothy grass 100,000 BAU/ml G 0.2 ml ALK 56789 7/09/09 6 7 8 9 10 Diluent HSA 0.6ml ALK 68597 12/12/11 Total 5.00 ml 6/09/09 Volume

** Assumes 0.5 ml injection as target maintenance dose

Maintenance Concentration Volume to add = Conc. Of Manufacturer’s Extract x Total volume volumevolume* BAU = Bioeqivalent Allergy Unit, AU =Allergy Unit PNU=Protein Nitrogen Unit W/V=Weight per Volume Ratio Maintenance concentration and subsequent dilutions reported G= 50 % Glycerinated as volume/volume (v/v) dilutions with maintenance Aq=Aqueous, Ly=Lyophilized concentration=1:1 v/v AP= Alum precipitated

Adapted from: Cox, L., et al., Allergen immunotherapy: A Practice Prameter Second Update. Journal of Allergy and Clinical Immunology, 2007: p. In press. (IV).